Provider Demographics
NPI:1689177594
Name:FULP GOOD, JASMINE MONIQUE
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:MONIQUE
Last Name:FULP GOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JASMINE
Other - Middle Name:MONIQUE
Other - Last Name:FULP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:284 EXECUTIVE PARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1833
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:704-939-1173
Practice Address - Street 1:1104A S MAIN ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292-3134
Practice Address - Country:US
Practice Address - Phone:336-242-2450
Practice Address - Fax:336-249-9920
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13832101YP2500X
NC26592-A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)